Myofascial Pain Syndromes and Trigger Point Injection Therapy

Dr John Whiteside MBBS, BSc

Perpetuating Factors

Introduction

In
order to understand perpetuating factors you need to understand the
global nature of myofascial trigger points. Skeletal muscle is the
largest single organ of the human body. It accounts for more than 40%
of the total body mass. As we progress through life taut bands develop
within skeletal muscle as a normal part of the aging process. Along
each taut band is a more sensitive region that is designated as a
trigger point. Trigger points can exist in different stages of
sensitivity. If they are very sensitive they are active. If they are
not very sensitive they are latent.

Active myofascial trigger point

Refers a pattern of pain at rest or at motion.

Usually refers pain on direct compression.

Mediates a local twitch response.

Tender to palpation.

Prevents full lengthening of muscle.Weakens the muscle.

Latent myofascial trigger point.

Clinically quiescent with respect to spontaneous pain.

May refer pain.

Tender to palpation.

Prevents full lengthening of muscle.

Weakens the muscle.

They accumulate from all of the vast number of physical things that happen to us.

If all our trigger points remain latent we gradually become stiffer and weaker.

If some become active we experience myofascial pain.

Prevalence

In
general practice it is my experience that approximately 70% of all pain
is primary Myofascial in origin. The remaining 30% has another cause
but is normally associated with a secondary myofascial pain
syndrome.The ratio will depend upon two things.

The group of patients being examined

The experience of the examiner.

Sports Injuries

Almost all are due to taut bands.Muscle tearing is sometimes present as an associated event.The associated muscle tear is self limiting.Treatment should be directed at the taut band not at the tear.

Treatment of all sports injuries.

Heat ASAP.

Never ice.

Stretch.

Ischaemic pressure / massage.

Mobilization.

The Pain Management Industry

The
pain management industry internationally has been directing itself at
"part of" "30 % of" the problem. This is why it is called a pain
management industry. " We cannot remove your pain but we can teach you
how to manage it."

It is my opinion that as myofascial therapy
becomes a routine part of the day to day work of health care
professionals then we will become a pain treatment industry.

Reasons why myofascial therapy fails.

The interdisciplinary myofascial team is not sufficiently skilled.Treatment is being directed at a secondary myofascial pain syndrome.Perpetuating factors are present.Perpetuating
Factors: Any physical, chemical or psychological factors that act to
increase trigger point activity in that individual, at that particular
time.

The following notes provide brief practical information about some of the perpetuating factors.

The detail of this subject is in chapter 4 of vol.1. of the Trigger Point Manual.

Leg Length Discrepancy (LLD)

The
problem of leg length discrepancy (LLD) and the method of assessment is
covered in detail in chapter 4 of vol. 1 and chapter 4 of vol. 2 of the
Trigger Point Manual.

Trigger points in the quadratus lumborum muscle must be released before an accurate measurement of LLD can be made.

The following is the protocol used at my clinic. At the initial assessment Assess LLDAssess quadratus lumborum bilaterally for trigger points.If
the quadratus lumborum muscles are not shortened and if no confident
diagnosis of LLD can be made, do not proceed to a trial of correction.
If a provisional diagnosis of LLD is made, with or without tight
quadratus lumborum muscles, reschedule the patient for a separate
session to begin a trial of correction.

Release quadratus
lumborum using procaine injection, spray & stretch, & heat.
Re-assess the LLD. Proceed to a trial of correction. If a LLD can be
confidently diagnosed an initial trial correction can be made in the
office be cutting a heel raise from sheets of ethyl vinyl acetate
(EVA). EVA can be purchased in different thickness from 1mm upward.
Using scissors, Stanley knife, and glue the heel raise can be made to
the thickness required by sticking appropriate layers together.

To
assess the thickness required I use test boards made to exact
thickness. I have the patient stand on a large board and then put
smaller test boards under the foot. These are made up to thickness of
1mm, 2mm (x 2), 5mm and 1cm.

With patience and trial and error
an estimate can be made of the LLD "theoretically" to an accuracy of 1
mm. In practice this is quite unrealistic, but the method produces a
starting point and the EVA heel inserts can be thickened or diminished
by 1mm steps as required. This simple method is valuable in simple
cases. If the LLD is large or if correction by heel raise alone is not
producing the desired result then a more rigorous approach is needed.
Review by podiatrist who makes up an orthotic to correct the
bio-mechanical factors at the ankle and foot level without adding a
heel raise.

Procaine injections to trigger points in quadratus
lumborum muscles bilaterally, followed by spray and stretch and heat.
Immediately following the procaine injections the patient proceeds to
the X-ray department. There an AP pelvic X-ray weight bearing is taken.
This is done with the orthotics in situ.

The difference in the
height of the femoral heads now provides an accurate measurement of the
leg length difference. The patient is then reviewed as soon as possible
by the podiatrist with the data from the X-rays. The orthotics are now
adjusted with the appropriate heel raise. Follow-up reviews by the
podiatrist and medical practitioner allow for fine adjustment of the
orthotics.

Small hemipelvis

Assess patient in seated
position. Release quadratus lumborum if possible before assessment.
Advise patient on a trial of butt lift using a folded towel or a
magazine.

Nutritional inadequacies

The prescription of
nutritional supplements by the practitioner will depend upon three
things. How much importance the practitioner places on this form of
therapy.

There is a commonly held belief that by eating the
Standard Australian Diet (SAD) sufficient nutrients are obtained to do
all things in all circumstances. I strongly recommend the course run by
the Australasian College of Nutritional and Environmental Medicine
(ACNEM). This provides the supportive evidence for the prescription of
nutritional Supplements. Details can be obtained by telephoning (03)
9589 6088

The patient's attitude to taking supplements and the cost of the program are influential factors.

Basic Vitamin Program

The
rationale behind prescribing nutritional supplements is primarily to
improve the efficiency of the body to neutralize free radicals. Damage
by free radicals is thought to impair the capacity of the body to
repair itself.

Anti-oxidants are substances that counter the
oxidative process and formation of the potentially highly toxic free
radicals.The main anti-oxidants are C,E,Selenium, Zinc and A.Listed
below is a basic program that offers a good high dose anti-oxidant
support at a cost of $7.00 to $10.00 per week.Basic Program $7.00 to
$10.00 per week.

Selenite
B tablets -Vita Glow. Formula 33 Note: Increase vitamin C supplement
according to the level of physical, chemical, and emotional stress.
Patients should take 1g of C before & after sessions of injection
therapy and increase to 1g four times daily for several days until post
treatment soreness is gone. Athletes normally require 500 IU twice
daily of vitamin E to assist tissue repair after training and decrease
post training muscle soreness.

A higher dose multi B is often
needed in the early stages of treatment. The brand name multi B
preparations are balanced. Use thiamine as the parameter looking for
100-200mg daily in divided doses. This adds another $1.00 - $4.00 per
day.

Magnesium 20 to 200mg of elemental magnesium per day (an extra $1-$15 per week)

Powerful muscle relaxant. Now used intravenously in many coronary care units.

Indicated
where skeletal muscle is generally tight, exhibits tics or
fibrillations, or cramps easily, or where cardiac palpitations are
present. Excellent for athletes before & after intensive training
sessions or competitions.

Metabolic & endocrine inadequacies

This topic is well covered in chapter 4 vol.1.

The most important perpetuating factor in this category is the pathology caused by oestrogen /progesterone imbalance in women.

I
strongly recommend the book Natural Progesterone by John R Lee MD. This
makes the treatment of this problem so simple and provides an
efficient, natural way of removing this very common and powerful
perpetuating factor. Details on the availability of natural
progesterone cream are available by telephoning Michael Buckley,
Pharmacist on (08) 9271 1956. Copies of the book by John R Lee MD can
also be purchased from Michael.

Psychological factors

Stress
is the most important perpetuating factor. "Neuropeptides such as
endorphins, are released during different emotional states. The
neuropeptides bind to opiate receptors which have been found to be
present on the surface of virtually every cell in the body, including
the immune and endocrine system. High levels of endorphins promote well
being and improve immunity." Ref: Healing and the Mind, B Moyers,
Doubleday 1993.

Infections: These act as powerful perpetuating
factors.. I ask the patients not to come in for injection therapy if
they have an active upper respiratory tract infection or
gastroenteritis.

Allergies: Both environmental and nutritional
allergies can act as perpetuating factor. A good history is important
to diagnose environmental factors. Elimination and challenge diet is
the only reliable way to diagnose food intolerance.

Sleep disorders

Active
myofascial trigger points produce sleep disturbance. Sleep disturbance
increases trigger point activity and lowers general health. The problem
will not resolve until the pain is removed. I prefer melatonin as an
hypnotic. More aggressive pharmaceutical medications may be needed in
some cases. Melatonin is an S4 item and can be obtained from Richard
Stenlake, Chemist, by telephone (02)

9387 3205. The dose for different ages is noted below.

Age Dose of Melatonin

40-50 0.5 - 1mg

45-55 1 - 2 mg

55-65 2 - 2.5 mg

65-75 2.5 - 5 mg

75 plus 3.5 - 5 mg

Melatonin
is a natural hormone that is produced by the pineal gland in the brain
and is responsible for the sleep wake cycle. Under natural lighting
conditions the pineal gland begins the production of melatonin when it
becomes dark and when it becomes light the melatonin production ceases.
Melatonin is produced by the pineal gland in large quantities during
youth and this explains why teenagers can sleep for long periods of
time. As we get older the production of melatonin decreases and it
becomes more difficult to complete a full nights sleep without waking
frequently in the second half of the night. People in their 60's and
older often state that they only need 5 to 6 hours sleep per night.
They need more sleep than this but are unable to get it because their
melatonin levels are too low. It is possible to restore sleep to its
natural youthful levels by taking a melatonin supplement. The dose for
your age needs to be calculated. Once this has been done a prescription
is written and this is then sent to a pharmacist in Sydney (details are
listed below). The pharmacist will keep the prescription including the
repeats and you can telephone for further supplies as needed. To get
started taking melatonin you need to be advised of the correct dose for
your age. Make contact with the pharmacist in Sydney and check the cost
of the prescription plus freight. Make sure you sign and date the
prescription and then mail it to the chemist in Sydney. There are
considerable individual differences with regard to the tolerance for
melatonin. If you find that the dose you are taking leaves you to
sleepy in the first few hours of the following day then a lower dose
may be required. If you are waking early in the morning with the dose
you are prescribed it is quite safe to increase the dose in a trial and
error basis to find the dose that suits you best. Any questions that
you have can be directed to me at the clinic.

Dental
perpetuating factorsThe medical practitioner's role is to physically
treat the muscles of mastication using the procaine injection
technique. The dentist's role is threefold. Occlusal adjustment,
preferably with an electromyograph. Use of an occlusal splint where
necessary. In my opinion splint therapy should not be the treatment of
first choice and provided only for a short time while the muscles of
mastication are injected. Removal of mercury amalgams. Mercury is a
toxic substance. Mercury amalgams in a solution of saliva produce an
electric current. This is even more prominent when a gold filling is
also present. This electrical activity increases the sensitivity of the
trigger points in the muscles of mastication.

On Monday almost every patient you see with pain will have myofascial trigger points.

Finding the clinical material is easy. What do you do with the jungle of information called perpetuating factors?

Myofascial Pain Syndromes:

Simple-Tend to begin treatment immediately and see what happens. Sports injuries.